Frequently Asked Questions
The ACOEM Guidelines combine findings from the highest quality studies in treatment for work-related injury and illness with the experience and contributions of some of the most esteemed medical specialty experts, creating a state-of-the art reference for managing common health problems and functional recovery in workers.
The administrative procedure used to process a claim for service according to the covered benefit.
Agreed Upon Medical Exam (AME)
If the claimant has an attorney, the attorney and the claims administrator may agree on a doctor without picking a Qualified Medical Evaluator (QME) to perform the exam. The doctor their attorney and the claims administrator agree on is called an agreed medical evaluator (AME). An AME can only be used if the claimant is represented by an attorney. Once an AME is seen, the claimant is not entitled to see a QME. An AME physician may be a QME, but does not have to be one.
American Medical Association (AMA)
A national physicians’ group that publishes a set of guidelines called “Guides to the Evaluation of Permanent Impairment.”
American Translations Association (ATA)
ATA is a professional association founded to advance the translation and interpreting professions and foster the professional development of individual translators and interpreters. Its 10,000 members in more than 90 countries include translators, interpreters, teachers, project managers, web and software developers, language company owners, hospitals, universities, and government agencies.
Americans with Disabilities Act (ADA)
The ADA is a federal law that prohibits discrimination against people with disabilities.
Auto Injury Management Services (AIMS)
Designed specifically for auto payers, AIMS professionals, through the prospective review of medical treatment and procedures, determine whether the policyholder is receiving the appropriate level of medical care and whether the treatment plan is medically necessary.
Auto Insurance Cost Reduction Act of 1998 (AICRA)
This New Jersey act requires practitioners to provide notification of intended medical procedures, treatments, diagnostic tests or other services, non-medical expenses and durable medical equipment. For additional information, click here to access the Insurance Council of New Jersey (http://www.icnj.org/AICRA.asp) or State of New Jersey Department of Banking and Insurance (http://www.state.nj.us/dobi/index.html) websites.
The evaluation and adjudication of provider bills for appropriateness of charges relating to medical necessity, prevailing rates, duplicate charges, unbundling of charges, relativeness of services to injury or illness, necessity of assistant surgeons, adjudication of multiple procedures, number of modalities, global procedures, and any other prevailing adjudication issues that may apply.
Case Management Approach
The goal of case management is to bring some form of external control into the medical care process by ensuring there is a comprehensive treatment plan in place which facilitates the injured worker’s or auto policyholder’s functional recovery.
The Centers for Medicare & Medicaid Services (CMS)
Regional CMS offices review and approve the Medicare Set-Aside dollar amount of settlement packages.
Class I Beneficiary
A patient is a Class I beneficiary if Medicare eligible at the time of settlement.
Class II Beneficiary
A patient is a Class II beneficiary if there is “Reasonable Expectation” that the claimant will be Medicare eligible within 30 months of the date of settlement AND the value of the settlement (Medical AND Indemnity) is $250,000 or more.
Clinical oversight describes patient care activities performed by a clinical staff of pharmacists and nurses to ensure quality of care.
Concurrent care exists where more than one physician renders services more extensive than consultative services during a period of time.
Medicare has a responsibility to pay for covered medical expenses only after another insurer, who is deemed the primary payer, has made payment. The statute intentionally shifts the financial burden for covered medical expenses from Medicare to other insurers that Congress has determined must be primary payer. The Social Security Act prohibits Medicare from making payment if payment has been made, or can reasonably be expected to be made promptly by a third-party payer. If payment has not been made, or cannot be expected to be made promptly, Medicare may make a conditional payment, subject to reimbursement.
A copayment is a fixed (flat) dollar fee an individual insured pays each time he gets a professional service from a physician or ancillary medical technician.
Current Procedural Terminology, an accepted method developed by the American Medical Association in connection with the Health Care Financing Administration Common Procedure Coding System to describe a medical service by use of a numeric code. This has been established as the standard code set for reporting health care services in electronic transactions.
An agreed upon amount that must be paid by an insured person making a claim against an insurance policy before an insurer will pay any compensation for losses.
Disability is defined as a physical or mental impairment that limits life activities. A condition that makes engaging in physical, social and work activities difficult.
A process to prevent disability from occurring or to intervene early, following the start of a disability, to encourage and support continued employment.
Durable Medical Equipment (DME)
Equipment with a primary medical purpose and continually reused, such as wheelchairs, etc.
Fee for Service
Fee for Service is the full billed charge a provider invoices an insurer for services rendered.
A fee Schedule is an explicitly noted schedule used by the carrier to determine the eligible amount charged. The fee schedule used dramatically effects eligible and reimbursable charges.
Field Case Management (FCM)
The focus of on-site case management, like telephonic case management, is managing treatment, expediting recovery, and coordinating a safe return-to-work. On-site case management also promotes communication and removes barriers to claim resolution.
First Report of Injury (FROI)
A report that describes the events and injuries, prepared by the employer or other parties.
Functional Capacity Evaluation (FCE)
The purpose of a Functional Capacity Evaluation (FCE) is to provide an objective measure of a patient's/client's safe functional abilities compared to the physical demands of work.
The International Statistical Classification of Diseases and Related Health Problems – Version 9 (most commonly known by the abbreviation ICD 9) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six characters long.
Independent Medical Review (IMR)
IMR is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Physicians who perform independent medical reviews must be board certified and in active practice in that same area of treatment. These physicians are contracted by an independent review organization, medical management companies, third party administrators (TPAs) or utilization review companies to provide objective, unbiased determinations on what the root cause of the treatment was, whether or not there is medical necessity.
In-network care is care received within the approved network.
Life Care Plan (LCP)
A dynamic document based on published standards of practice, a comprehensive assessment, data analysis and research. The LCP provides a concise plan for current and future medical needs and associated costs for individuals who have experienced catastrophic injury or have chronic care needs.
Medical delivery system that attempts to manage the quality and cost of medical services that individual receives. Managed care programs are a form of external management into the medical care and rehabilitation processes for injured workers and auto policyholders with the goal of controlling costs and ensuring efficient use of resources.
Managed Care Organizations (MCOs)
Managed care organizations deliver timely, consistent, quality medical care through the use of treatment protocols and standards, medical treatment review, utilization review, and ongoing provider education.
Maximum Medical Improvement (MMI)
This is the level of medical recovery reached by an injured person when their physician determines that their condition is unlikely to improve further.
An integrated working relationship between the managed care organization and the healthcare providers whereby medical protocols are established.
Outlines the specific treatment options for a defined set of clinical symptoms or laboratory results. Accumulated outcomes databases are used to design these protocols.
A medically necessary service is a service or supply that is provided for and consistent with the symptoms, diagnosis, or treatment of a medical condition, and is consistent with generally accepted standards of medical practice.
Medicare Covered Expense
Expenses covered by Medicare. Coverage lists change periodically per federal regulations.
A patient is eligible for Medicare if he/she is 65 years or older, or has received Social Security disability for 24 months or longer, or is diagnosed with end stage renal disease (ESRD).
Medicare Secondary Payer (MSP)
MSP is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for first and second payment.)
Medicare Set-Aside (MSA)
The recommended method to protect Medicare’s interest in a settlement. A Medicare Set-Aside (MSA) arrangement is a document that specifies future injury-related medical needs and associated costs. Only Medicare-covered expenses are identified and costs are based upon what would ordinarily be paid by Medicare within the beneficiary’s state of jurisdiction. Based upon the MSA projection, part of a settlement award is “set-aside” in order to pay for the costs of future care which would ordinarily have been paid by Medicare.
Medical Provider Network (MPN)
A medical provider network (MPN) is an entity or group of health care providers set up by an insurer or self-insured employer and approved to treat workers injured on the job. MPNs are required to meet access to care standards for common occupational injuries and work-related illnesses. MPNs must offer an opportunity for second and third opinions if the injured worker disagrees with the diagnosis or treatment offered by the treating physician. If a disagreement still exists after the second and third opinion, an injured worker in the MPN may request an independent medical review (IMR).
National Alliance of Medicare Set-Aside Professionals (NAMSAP)
NAMSAP is the only non-profit association exclusively addressing the issues and challenges of the Medicare Secondary Payer Statute and its impact on workers’ compensation and liability settlements.
National Correct Coding Initiative (NCCI)
The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.
National Mobility Equipment Dealers Association (NMEDA)
NMEDA is a non-profit trade association of mobility equipment dealers, driver rehabilitation specialists, and other professionals dedicated to broadening the opportunities for people with disabilities to drive or be transported in vehicles modified with mobility equipment. All members work together to improve transportation options of people with disabilities.
National Structured Settlements Trade Association (NSSTA)
The National Structured Settlements Trade Association (NSSTA) represents more than 600 licensed insurance brokers, insurance companies and others involved in establishing structured settlements to resolve physical injury and workers' compensation claims. NSSTA promotes the establishment and preservation of structured settlements to provide long-term financial security to personal injury claimants and their families through advocacy, legislative action and education. Structured settlements provide long-term financial security to injury victims and their families through a stream of state and federal tax-free income tailored to their specific needs.
Nurse Case Manager (NCM)
Nurse case management services focus on influencing medical care by intervening with the physician to achieve maximum medical improvement and to minimize permanent disability, as well as on facilitating the disabled employee's safe and timely functional recovery. In addition, Nurse Case Management combined with other managed care services such as PPO networks and utilization review, help control medical costs.
Official Disability Guidelines (ODG)
The Official Disability Guidelines (ODG) provides the most up to date evidence-based medical treatment and disability duration guidelines to improve as well as benchmark outcomes in workers' compensation and non-occupational disability.
Out-of-network care is care received from a provider that is not part of the approved network of providers.
Personal Injury Protection (PIP)
Form of insurance that pays for loss of income and medical expenses resulting from an automobile accident. PIP may also cover accidental death and funeral expenses. This coverage may vary greatly from state to state.
Pharmacy Benefit Manager (PBM)
A Pharmacy Benefit Manager (PBM) is a third party administrator of prescription drug programs. They are primarily responsible for processing and paying prescription drug claims. They also are responsible for developing and maintaining the formulary, contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers.
Preferred Provider Organization (PPO)
A PPO is a group of physicians and /or hospitals who contract with an employer or managed care organization to provide medical services at a discounted fee.
Provider credentialing is an organized, systematic review process for identifying qualified providers.
A description of practice patterns on a disease-specific basis, comparison of these patterns to an appropriate peer group, and also comparison patterns, to validated benchmarks. By examining practice patterns, profiling seeks to promote cost-effective care.
Qualified Medical Exam (QME)
A qualified medical evaluator (QME) is a physician who evaluates patients when there are questions about what benefits should be received. A physician must meet educational and licensing requirements to qualify as a QME. They must also pass a test and participate in ongoing education on the workers' compensation evaluation process.
Reasonable and Customary
Reasonable and customary represents the range of usual fees for comparable services charged by the medical professionals in a geographic area.
Resource-Based Relative Value Scale (RBRVS)
Resource-Based Relative Value Scale (RBRVS) is a schematic used to determine how much money medical providers should be paid. It is currently used by Medicare and by nearly every Health maintenance organizations (HMOs).
A retrospective review is a post-treatment assessment of services on a case-by-case or aggregate basis after the services have been performed.
Return to work.
Specialty Healthcare Services
Supplemental services, including durable medical equipment and supplies, home health and catastrophic care services, diagnostic imaging services, home/vehicle/workplace modifications, physical medicine and transportation and language services that are provided outside of hospital and physician services.
Telephonic Case Management (TCM)
Telephonic Case Management (TCM) is an early intervention, short term cost management service and is most effective when implemented immediately after injury.
A process that monitors the use of a comprehensive set of integrated components including: pre-certification review, admission review, continued stay review, retrospective review, discharge planning, bill review and individual medical case management as required for determining medical necessity, cost effectiveness, and conformity to criteria for optimal use.
Utilization Review (UR)
Utilization review is the determination of medical necessity for medical and surgical in-hospital, outpatient, and alternative setting treatments for acute and rehabilitation care.
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